Carriers科讯cms

CMSManualSystemDepartmentofHealth&HumanServices(DHHS)Pub100-04MedicareClaimsProcessingCenterforMedicare&MedicaidServices(CMS)Transmittal668Date:SEPTEMBER2,2005ChangeRequest3933Transmittal622,datedJuly29,2005isrescindedandreplacedwithTransmittal668,datedSeptember2,2005.
TheonlychangesareinthelastsentenceoftheSUMMARYOFCHANGESparagraphonthistransmittalandtheBackgroundparagraphintheBusinessRequirementsattachmenttoshow"paymentbycarriers"insteadof"paymenttocarriers.
"Allotherinformationremainsthesame.
SUBJECT:EnforcementofHospitalInpatientBundling:CarrierDenialofAmbulanceClaimsduringanInpatientStayI.
SUMMARYOFCHANGES:AsaresultofreportsfromtheBostonRegionalOfficeoftheInspectorGeneral(OIG),CMShasbeenmadeawareofimproperpaymentsforambulanceservicesprovidedtohospitalinpatientsbyindependentsuppliersofambulanceservices.
Sections1882(a)(14),1886(d)and(g)oftheSocialSecurityActaswellasCFR411.
15(m)excludepaymentforambulanceservicesfurnishedtohospitalinpatientswithintheadmissionanddischargedatesunlessbilleddirectlybythehospitalorfurnishedunderarrangements.
Withtheexceptionoftheadmissionanddischargedates,alltransportationprovidedtohospitalinpatientsmustbebundledtothehospital.
Ambulanceservicesthatarebilledtothecarrierwithadateofservicethatfallswithintheadmissionordischargedateonahospitalinpatientbillshallberejected.
TherearecurrentlynoeditsintheCommonWorkingFile(CWF)topreventpaymentbycarriersforservicesthatarebundledinthehospital'spayment.
NEW/REVISEDMATERIAL:EFFECTIVEDATE:AmbulanceclaimsreceivedonorafterJanuary3,2006,and4yearsafterinitialdeterminationforadjustmentsIMPLEMENTATIONDATE:January3,2006Disclaimerformanualchangesonly:Therevisiondateandtransmittalnumberapplyonlytoreditalicizedmaterial.
Anyothermaterialwaspreviouslypublishedandremainsunchanged.
However,ifthisrevisioncontainsatableofcontents,youwillreceivethenew/revisedinformationonly,andnottheentiretableofcontents.
II.
CHANGESINMANUALINSTRUCTIONS:(N/Aifmanualisnotupdated)R=REVISED,N=NEW,D=DELETED–OnlyOnePerRow.
R/N/DChapter/Section/Subsection/TitleR3/TableofContentsN3/10.
5/HospitalInpatientBundlingR15/TableofContentsR15/10/GeneralCoverageandPaymentPoliciesN15/30.
1.
4/CWFEditingofAmbulanceClaimsforInpatientsR15/30.
2/IntermediaryGuidelinesR15/30.
2.
1/Provider/IntermediaryBillProcessingGuidelinesEffectiveApril1,2002,asaResultofFeeScheduleImplementationIII.
FUNDING:NoadditionalfundingwillbeprovidedbyCMS;ContractoractivitiesaretobecarriedoutwithintheirFY2006operatingbudgets.
IV.
ATTACHMENTS:BusinessRequirementsManualInstructions*Unlessotherwisespecified,theeffectivedateisthedateofservice.
Attachment-BusinessRequirementsPub.
100-04Transmittal668Date:September2,2005ChangeRequest3933Transmittal622,datedJuly29,2005isrescindedandreplacedwithTransmittal668,datedSeptember2,2005.
TheonlychangesareinthelastsentenceoftheSUMMARYOFCHANGESparagraphonthetransmittalandtheBackgroundparagraphintheBusinessRequirementsattachmenttoshow"paymentbycarriers"insteadof"paymenttocarriers.
"Allotherinformationremainsthesame.
SUBJECT:EnforcementofHospitalInpatientBundling:CarrierDenialofAmbulanceClaimsduringanInpatientStayI.
GENERALINFORMATIONA.
Background:AsaresultofreportsfromtheBostonRegionalOfficeoftheInspectorGeneral(OIG),CMShasbeenmadeawareofimproperpaymentsforambulanceservicesprovidedtohospitalinpatientsbyindependentsuppliersofambulanceservices.
§1882(a)(14),1886(d)and(g)oftheSocialSecurityActaswellasCFR411.
15(m)excludepaymentforambulanceservicesfurnishedtohospitalinpatientswithintheadmissionanddischargedatesunlessbilleddirectlybythehospitalorfurnishedunderarrangements.
Asaresult,theindependentsupplierofambulanceservicesmustlooktothehospital,ratherthantothebeneficiaryorcarrier,forpayment.
Withtheexceptionoftheadmissionanddischargedates,alltransportationprovidedtohospitalinpatientsmustbebundledtothehospital.
Ambulanceservicesthatarebilledtothecarrierwithadateofservicethatfallswithintheadmissionordischargedateonahospitalinpatientbillshallberejected.
TherearecurrentlynoeditsintheCommonWorkingFile(CWF)topreventpaymentbycarriersforservicesthatshouldbebundledinthehospital'spayment.
B.
Policy:AmbulancetransportationthatisprovidedwithintheadmissionanddischargedatesforhospitalinpatientsbyanindependentsupplierofambulanceservicesshallnotbepaidseparatelyasaPartBservice.
TheCWFshallrejectanambulancelineitemreceivedbythecarrierfromanindependentsupplierofambulanceserviceswhentheambulancelineitemservicedatefallswithintheadmissionanddischargedatesonahospitalinpatientbillthatispostedtotheCWF.
TheCWFrejectshallindicatethattheambulancetransportationoccurredduringahospitalinpatientstay,andisnotseparatelypayable.
TheCWFwillbypasstherejecteditwhentheambulancelineitemservicedateisthesameastheadmissionordischargedateonahospitalinpatientbill.
Iftheambulanceclaimisreceivedpriortothehospitalinpatientbill,uponreceiptofthehospitalinpatientbillCWFshallgenerateanunsolicitedresponsetothecarrierthatprocessedtheclaimindicatingtheambulancelineitemshouldbeadjustedandpaymentrecouped.
TheCWFshallperformanadditionaleditbeforedeterminingiftheambulancelineitemshouldberejectedwhenthebeneficiaryisaninpatientofalongtermcarefacility(LTCH),inpatientpsychiatricfacility(IPF)orinpatientrehabilitationfacility(IRF)andistransportedviaambulancetoanacutecarehospitaltoreceivespecializedservices.
TheCWFshalledittheclaimforthepresenceofoccurrencespancode74(non-coveredlevelofcare)andtheassociatedoccurrencespancodefromandthroughdates.
TheCWFshallbypasstherejecteditwhentheambulancelineitemservicedatefallswithintheoccurrencespancode74fromandthroughdatesplusoneday.
Inthiscase,theambulancelineitemisseparatelypayable.
TheCWFshallrejecttheambulancelineitemwhentheservicedatefallsoutsideoftheoccurrencespancode74fromandthroughdatesplusoneday.
IftheambulanceclaimisreceivedpriortotheLTCH,IPForIRFbill,uponreceiptofthehospitalinpatientbillCWFshallgenerateanunsolicitedresponsetothecarrierthatprocessedtheclaimindicatingtheambulancelineitemshouldbeadjustedandpaymentrecouped.
BasedontheCWFlineitemrejects,carriersshalldenyambulancelineitemsthatshouldbebundledtothehospital.
Appealsrightsshallbeofferedonalldenials.
Standardsystemsshalldevelop,andalongwithcarriersshallimplement,anautomatedresolutionprocesswherebywhentheyreceivearejectfromCWF,theyshallpaythoseservicescorrectlybilledanddenyonlythoseservicesontheclaimincorrectlybilledtothem.
CWFshallallowanoverrideoftherejectforcarrieruse,whereinthecourseofpursuingareconsideration,aproviderorsuppliermaybringtotheattentionofthecarrierasituationwhereservicesonaclaimhavebeendenied,butshouldactuallybeallowedtobepaidthroughthecarrier.
Atthecarrier'sdiscretion,thecarriermayusetheoverridecodetoallowthatclaimtoprocessthroughCWFtopayment.
TheoverridecodewillbespecifiedintheCWFdocumentation.
II.
BUSINESSREQUIREMENTS"Shall"denotesamandatoryrequirement"Should"denotesanoptionalrequirementRequirementNumberRequirementsResponsibility("X"indicatesthecolumnsthatapply)SharedSystemMaintainersFIRHHICarrierDMERCFISSMCSVMSCWFOther3933.
1TheCWFSystemMaintainershallcreateanedittorejectaPartBambulancespecialty"59"lineitemreceivedonorafter01/3/2006withaservicedatethatfallswithintheadmissionanddischargedatesofacoveredhospitalinpatientstaypostedtotheCWF.
X3933.
1.
1Effectiveforclaimsreceivedonorafter01/3/2006,thecarriershallrejectaPartBambulancespecialty"59"lineitemwithaservicedatethatfallswithintheadmissionanddischargedatesofacoveredhospitalinpatientstaypostedtotheCWF.
XXRequirementNumberRequirementsResponsibility("X"indicatesthecolumnsthatapply)SharedSystemMaintainersFIRHHICarrierDMERCFISSMCSVMSCWFOther3933.
1.
2ThecarriershalluseRemittanceAdviceRemarkCodeM2:"Notpaidseparatelywhenthepatientisaninpatient,"whenrejectingaPartBambulancespecialty"59"lineitemwithaservicedatethatfallswithintheadmissionanddischargedatesofacoveredhospitalinpatientstaypostedtotheCWF.
XX3933.
1.
3ThecarriershalluseMSNmessage16.
27:"Thisserviceisnotcoveredsinceourrecordsshowyouwereinthehospitalatthistime,"whenrejectingaPartBambulancespecialty"59"lineitemwithaservicedatethatfallswithintheadmissionanddischargedatesofacoveredhospitalinpatientstaypostedtotheCWF.
XX3933.
1.
4TheCWFSystemMaintainershallbypasstheeditonaPartBambulancespecialty"59"lineiteminthefollowingsituations:-theincomingPartBambulancelineitemservicedatematchestheadmissionordischargedateofacoveredhospitalinpatientstaypostedtotheCWF,-thePartBambulanceclaimisacancelonlyclaim(ActionCode3),-thePartBambulanceclaimisanaccreteclaim(ActionCode9),-thePartBambulanceservicehasaPaymentProcessIndicatorotherthanA(allowed),or-theCWFoverridecodeusedforbundlingispresent.
X3933.
2TheCWFSystemMaintainershalladdtotheunsolicitedprocesstheeditlogicforrejectingaPartBambulancespecialty"59"lineitemwithaservicedatethatfallswithintheadmissionanddischargedatesonanincominghospitalinpatientbill.
XRequirementNumberRequirementsResponsibility("X"indicatesthecolumnsthatapply)SharedSystemMaintainersFIRHHICarrierDMERCFISSMCSVMSCWFOther3933.
2.
1ThecarriershalladjustaPartBambulancespecialty"59"lineitemandrecoupthepaymentwhenanunsolicitedresponseisreceivedforalineitemwithaservicedatethatfallswithintheadmissionanddischargedatesonanincominghospitalinpatientbill.
XX3933.
2.
2ThecarriershalluseRemittanceAdviceRemarkCodeM2:"Notpaidseparatelywhenthepatientisaninpatient,"whenadjustingaPartBambulancespecialty"59"lineitemwithaservicedatethatfallswithintheadmissionanddischargedatesonanincominghospitalinpatientbill.
XX3933.
2.
3ThecarriershalluseRemittanceAdvice(RA)AdjustmentReasonCode97"Paymentisincludedintheallowanceforanotherservice/procedure",whenadjustingaPartBambulancespecialty"59"lineitemwithaservicedatethatfallswithintheadmissionanddischargedatesonanincominghospitalinpatientbill.
XX3933.
2.
4ThecarriershalluseMSNmessage16.
27:"Thisserviceisnotcoveredsinceourrecordsshowyouwereinthehospitalatthistime,"whenadjustingaPartBambulancespecialty"59"lineitemwithaservicedatethatfallswithintheadmissionanddischargedatesonanincominghospitalinpatientbill.
XX3933.
3TheCWFSystemMaintainershallcreateanedittorejectaPartBambulancespecialty"59"lineitemreceivedonorafter01/3/2006withaservicedatethatfallsoutsidetheoccurrencespancode74(non-coveredlevelofcare)fromandthroughdatesplusonedayonaLTCH,IPForIRFbillpostedtotheCWF.
XRequirementNumberRequirementsResponsibility("X"indicatesthecolumnsthatapply)SharedSystemMaintainersFIRHHICarrierDMERCFISSMCSVMSCWFOther3933.
3.
1Effectiveforclaimsreceivedonorafter01/3/2006,thecarriershallrejectanincomingPartBambulancespecialty"59"lineitemwithaservicedatethatfallsoutsidetheoccurrencespancode74(non-coveredlevelofcare)fromandthroughdatesplusonedayonaLTCH,IPForIRFbillpostedtotheCWF.
XX3933.
3.
2ThecarriershalluseRemittanceAdviceRemarkCodeM2:"Notpaidseparatelywhenthepatientisaninpatient,"whenrejectingaPartBambulancespecialty"59"lineitemwithaservicedatethatfallsoutsidetheoccurrencespancode74(non-coveredlevelofcare)fromandthroughdatesplusonedayonaLTCH,IPForIRFbillpostedtotheCWF.
XX3933.
3.
3ThecarriershalluseMSNmessage16.
27:"Thisserviceisnotcoveredsinceourrecordsshowyouwereinthehospitalatthistime,"whenrejectingaPartBambulancespecialty"59"lineitemwithadateofservicethatfallsoutsidetheoccurrencespancode74(non-coveredlevelofcare)fromandthroughdatesplusonedayonaLTCH,IPForIRFbillpostedtotheCWF.
XX3933.
3.
4TheCWFSystemMaintainershallbypasstheeditonaPartBambulancespecialty"59"lineiteminthefollowingsituations:-theservicedateontheincomingPartBambulanceservicelineitemfallswithintheoccurrencespancode74(non-coveredlevelofcare)fromandthroughdatesplusonedayonaLTCH,IPForIRFbillpostedtotheCWF.
-thePartBambulanceclaimisacancelonlyclaim(ActionCode3),-thePartBambulanceclaimisanaccreteclaim(ActionCode9),-thePartBambulanceservicehasaPaymentProcessIndicatorotherthanA(allowed),orXRequirementNumberRequirementsResponsibility("X"indicatesthecolumnsthatapply)SharedSystemMaintainersFIRHHICarrierDMERCFISSMCSVMSCWFOther-theCWFoverridecodeusedforbundlingispresent.
3933.
4TheCWFSystemMaintainershalladdtotheunsolicitedprocesstheeditlogicforadjustingaPartBambulancespecialty"59"lineitemwithaservicedatethatfallsoutsidetheoccurrencespancode74(non-coveredlevelofcare)fromandthroughdatesplusonedayonanincomingLTCH,IPForIRFbill.
X3933.
4.
1ThecarriershalladjustthePartBambulancespecialty"59"lineitemandrecoupthepaymentwhenanunsolicitedresponseisreceivedforalineitemwithaservicedatethatfallsoutsidetheoccurrencespancode74(non-coveredlevelofcare)fromandthroughdatesplusonedayonanincomingLTCH,IPForIRFbill.
XX3933.
4.
2ThecarriershalluseRemittanceAdviceRemarkCodeM2:"Notpaidseparatelywhenthepatientisaninpatient,"whenadjustingaPartBambulancespecialty"59"lineitemwithaservicedatethatfallsoutsidetheoccurrencespancode74(non-coveredlevelofcare)fromandthroughdatesplusonedayonanincomingLTCH,IPForIRFbill.
XX3933.
4.
3ThecarriershalluseRemittanceAdvice(RA)AdjustmentReasonCode97"Paymentisincludedintheallowanceforanotherservice/procedure",whenadjustingaPartBambulancespecialty"59"lineitemwithaservicedatethatfallsoutsidetheoccurrencespancode74(non-coveredlevelofcare)fromandthroughdatesplusonedayonanincomingLTCH,IPForIRFbill.
XXRequirementNumberRequirementsResponsibility("X"indicatesthecolumnsthatapply)SharedSystemMaintainersFIRHHICarrierDMERCFISSMCSVMSCWFOther3933.
4.
4ThecarriershalluseMSNmessage16.
27:"Thisserviceisnotcoveredsinceourrecordsshowyouwereinthehospitalatthistime,"whenadjustingaPartBambulancespecialty"59"lineitemwithaservicedatethatfallsoutsidetheoccurrencespancode74(non-coveredlevelofcare)fromandthroughdatesplusonedayonanincomingLTCH,IPForIRFbill.
XX3933.
5Carriersshouldnotsearchtheirfilestoeitherretractpaymentorretroactivelypayclaims.
X3933.
6Carriersshalladjustclaimsiftheyarebroughttotheirattention.
X3933.
7CarriersandstandardsystemsshallimplementanautomatedresolutionprocessforCWFrejects,payingthoseservicescorrectlybilledanddenyingthoseservicesontheclaimincorrectlybilled.
XXIII.
PROVIDEREDUCATIONRequirementNumberRequirementsResponsibility("X"indicatesthecolumnsthatapply)SharedSystemMaintainersFIRHHICarrierDMERCFISSMCSVMSCWFOther3933.
8Aprovidereducationarticlerelatedtothisinstructionwillbeavailableatwww.
cms.
hhs.
gov/medlearn/mattersshortlyaftertheCRisreleased.
Youwillreceivenotificationofthearticlereleaseviatheestablished"medlearnmatters"listserv.
Contractorsshallpostthisarticle,oradirectlinktothisarticle,ontheirWebsiteandincludeinformationaboutitinalistservmessagewithin1weekoftheavailabilityoftheprovidereducationarticle.
Inaddition,theprovidereducationarticleshallbeincludedinyournextregularlyscheduledbulletinandincorporatedintoanyeducationaleventsonthistopic.
ContractorsarefreetosupplementMedlearnMattersarticleswithlocalizedinformationthatwouldbenefittheirprovidercommunityinbillingandadministeringtheMedicareprogramcorrectly.
XXIV.
SUPPORTINGINFORMATIONANDPOSSIBLEDESIGNCONSIDERATIONSA.
OtherInstructions:CWFshallsetuptestHealthInsuranceClaimNumbers(HICNs)andunsolicitedresponsestobeusedbythecarrierfortesting.
X-RefRequirement#InstructionsB.
DesignConsiderations:N/AX-RefRequirement#RecommendationforMedicareSystemRequirementsC.
Interfaces:N/AD.
ContractorFinancialReporting/WorkloadImpact:N/AE.
Dependencies:N/AF.
TestingConsiderations:N/AV.
SCHEDULE,CONTACTS,ANDFUNDINGEffectiveDate:AmbulanceclaimsreceivedonorafterJanuary3,2006,and4yearsafterinitialdeterminationforadjustmentsImplementationDate:January3,2006Pre-ImplementationContact(s):SusanGuerin(410-786-6138)orsusan.
guerin@cms.
hhs.
gov(forFIrelatedissues)orJoanProctorYoung(410-786-0949)or(joan.
proctoryoung@cms.
hhs.
govforcarrierrelatedissues)Post-ImplementationContact(s):AppropriateRegionalOfficeNoadditionalfundingwillbeprovidedbyCMS;contractoractivitiesaretobecarriedoutwithintheirFY2006operatingbudgets.
*Unlessotherwisespecified,theeffectivedateisthedateofservice.
MedicareClaimsProcessingManualChapter3-InpatientHospitalBillingTableofContents(Rev.
668,09-02-05)10.
5HospitalInpatientBundling10.
5–HospitalInpatientBundling(Rev.
668,Issued:09-02-05,Effective:01-03-06,Implementation:01-03-06)Hospitalbundlingrulesexcludepaymenttoindependentsuppliersofambulanceservicesforbeneficiariesinahospitalinpatientstay.
TheCommonWorkingFile(CWF)performsrejecteditstoincomingclaimsfromindependentsuppliersofambulanceservices.
TheCWFsearchespaidclaimhistoryandcomparesthelineitemservicedateonanambulanceclaimtotheadmissionanddischargedatesonahospitalinpatientstay.
TheCWFrejectsthelineitemwhentheambulancelineitemservicedatefallswithintheadmissionanddischargedatesonahospitalinpatientclaim.
BasedonCWFrejects,thecarriermustdenylineitemsforambulanceservicesbilledbyindependentsuppliersthatshouldbebundledtothehospital.
Uponreceiptofahospitalinpatientclaim,CWFsearchespaidclaimhistoryandcomparestheperiodbetweenthehospitalinpatientadmissionanddischargedatestothelineitemservicedateonanambulanceclaimbilledbyanindependentsupplier.
TheCWFshallgenerateanunsolicitedresponsewhenthelineitemservicedatefallswithintheadmissionanddischargedatesofthehospitalinpatientclaim.
Uponreceiptoftheunsolicitedresponse,thecarriershalladjusttheambulanceclaimandrecoupthepayment.
Ambulanceserviceswithadateofservicethatisthesameastheadmissionordischargedateonaninpatientclaimareseparatelypayableandnotsubjecttothebundlingrules.
TheCWFperformsanadditionaleditbeforedeterminingiftheambulancelineitemshouldberejectedwhenthebeneficiaryisaninpatientofalongtermcarefacility(LTCH),inpatientpsychiatricfacility(IPF)orinpatientrehabilitationfacility(IRF)andistransportedviaambulancetoanacutecarehospitaltoreceivespecializedservices.
TheCWFeditstheclaimforthepresenceofoccurrencespancode74(non-coveredlevelofcare)andtheassociatedoccurrencespancodefromandthroughdates.
TheCWFbypassestherejecteditwhentheambulancelineitemservicedatefallswithintheoccurrencespancode74fromandthroughdatesplusoneday.
Inthiscase,theambulancelineitemisseparatelypayable.
TheCWFrejectstheambulancelineitemwhentheservicedatefallsoutsidetheoccurrencespancode74fromandthroughdatesplusoneday.
MedicareClaimsProcessingManualChapter15-AmbulanceTableofContents(Rev.
668,09-02-05)30.
1.
4CWFEditingofAmbulanceClaimsforInpatients10-GeneralCoverageandPaymentPolicies(Rev.
668,Issued:09-02-05,Effective:01-03-06,Implementation:01-03-06)Theseinstructionsapplytoprocessingclaimstocarriersandintermediariesundertheambulancefeeschedule(FS).
GeneralrulesforcoverageofambulanceservicesareintheMedicareBenefitPolicyManual,Chapter10.
GeneralmedicalreviewinstructionsforambulanceservicesareinChapter6oftheMedicareProgramIntegrityManual.
Ingeneral,effectiveApril1,2002,paymentisbasedonthelevelofserviceprovided,notonthevehicleused.
However,twotemporaryQcodes(Q3019andQ3020)areavailableforuseduringthetransitionperiodwhenanALSvehicleisusedforaMedicare-coveredtransport,butnoALSserviceisfurnished.
AmbulanceservicesareseparatelyreimbursableonlyunderPartB.
Onceabeneficiaryisadmittedtoahospital,CriticalAccessHospitals(CAH),orSkilledNursingFacility(SNF),itmaybenecessarytotransportthebeneficiarytoanotherhospitalorothersitetemporarilyforspecializedcarewhilethebeneficiarymaintainsinpatientstatuswiththeoriginalprovider.
Thismovementofthepatientisconsidered"patienttransportation"andiscoveredasaninpatienthospitalorCAHserviceunderPartAandasaSNFservicewhentheSNFisfurnishingitasacoveredSNFserviceandPartApaymentismadeforthatservice.
BecausetheserviceiscoveredandpayableasabeneficiarytransportationserviceunderPartA,theservicecannotbeclassifiedandpaidforasanambulanceserviceunderPartB.
Thisincludesintra-campustransfersbetweendifferentdepartmentsofthesamehospital,evenwherethedepartmentsarelocatedinseparatebuildings.
Suchintra-campustransfersarenotseparatelypayableunderthePartBambulancebenefit.
Suchcostsareaccountedforinthesamemannerasthecostsofsuchatransferwithinasinglebuilding.
Seesection10.
3.
3ofChapter10oftheMedicareBenefitPolicyManualforfurtherdetails.
Refertosection10.
5ofChapter3oftheMedicareClaimsProcessingManualforadditionalinformationonhospitalinpatientbundlingofambulanceservices.
PriortotheimplementationoftheFS,suppliersusedoneoffourbillingmethods.
Providersusedonlyonebillingmethod,method2.
TheFS(effectiveApril1,2002)hasonlyonebillingmethod,formerlymethod2.
ThiscurrentbillingmethodincludespaymentforallitemsandservicesintheambulanceFSbaserateexceptforthecostofmileage,whichispayableseparatefromthebaserate.
NOTE:Thecostofoxygenanditsadministrationinconnectionwithandaspartoftheambulanceserviceiscovered.
UndertheambulanceFSoxygenandotheritemsandservicesprovidedaspartofthetransportareincludedintheFSbasepaymentrateandaregenerallyNOTseparatelypayable.
Theintermediaryisresponsiblefortheprocessingofclaimsforambulanceservicesfurnishedbyproviders;i.
e.
,hospitalsandskillednursingfacilities.
Thecarrierisresponsibleforprocessingclaimsfromsuppliers;i.
e.
,thoseentitiesthatarenotownedandoperatedbyaprovider.
EffectiveDecember21,2000,ambulanceservicesfurnishedbyaCAHoranentitythatisownedandoperatedbyaCAHarepaidonareasonablecostbasis,butonlyiftheCAHorentityistheonlyproviderorsupplierofambulanceserviceslocatedwithina35-miledriveofsuchCAHorentity.
BeginningFebruary24,1999,ambulancetransportstoorfromanonhospital-baseddialysisfacility,originanddestinationmodifier"J,"satisfytheprogram'soriginanddestinationrequirementsforcoverage.
Ambulancesupplierservicesfurnishedunderarrangementswithaprovider,e.
g.
,hospitalorSNFarenotbilledbythesuppliertoitscarrier,butarebilledbytheprovidertoitsintermediary.
Theintermediaryisresponsiblefordeterminingwhethertheconditionsdescribedbelowaremet.
Incaseswhereallorpartoftheambulanceservicesarebilledtothecarrier,thecarrierhasthisresponsibility,andtheintermediarymustcontactthecarriertoascertainwhetherithasalreadydeterminedifthecrewandambulancerequirementsaremet.
Insuchasituation,theintermediaryshouldacceptthecarrier'sdeterminationwithoutpursuingitsowninvestigation.
Whereaproviderfurnishesambulanceservicesunderarrangementswithasupplierofambulanceservices,suchservicescanbecoveredonlyifthesupplier'svehiclesandcrewmeetthecertificationrequirementsapplicableforindependentambulancesuppliers.
TheambulanceFSiseffectiveforclaimswithdatesofserviceonorafterApril1,2002.
TheFSisphasedinoveratransitionperiodthroughtheendof2005.
Duringthetransitionperiodpaymentamountsareablendedamount:partambulanceFS,andpartreasonablecharge(forindependentsuppliers)orreasonablecostforproviders.
Thepercentagesfortheblendedrateduringthetransitionperiodareasfollows:TransitionYearReasonableCharge/CostPercentFSPercentYearOne(4/1/2002-12/2002)8020YearTwo(CY2003)6040YearThree(CY2004)4060YearFour(CY2005)2080YearFive(CY2006)0100Whencarriersreceiveaclaimonwhichthesubmittedchargesubstantiallyexceedsthenormalreasonablechargeamountforwaitingtime,theymustsendittotheutilizationreviewunitforitsreview.
Oncethereviewunithasmadeadeterminationtopayanamounthigherthanthecustomaryorprevailingcharge,documentationtosupportthereasonforthisdeterminationmustaccompanytheclaim.
NOTE:Tobillmileage,providersandsupplierscontinuetousecodesA0380andA0390fordatesofserviceJanuary1,2001throughMarch31,2002.
SuppliersusingMethod3or4mayusesupplycodesA0382,A0384,andA0392-A0999aswellasJ-codesandcodesforEKGtestingduringthetransitionperiod.
Thesesupplycodesshouldbeenteredinitem22.
CarriersdenyclaimsforitemsfromMethod1andMethod2billers.
TheZIPcodeofthepointofpickupmustbeenteredinitem12.
IfthereisnoZIPcodeinitem12,oriftherearemultipleZIPcodesinitem12,carriersreturntheclaimasunprocessable.
TheZIPcodeenteredinitem12mustbeeditedforvalidity.
TheformatforaZIPcodeisfivenumerics.
IftheZIPcodeinitem12showsa9-digitZIPcode,carriersvalidateonlythefirst5digits.
IftheZIPcodeenteredintoitem12doesnotcorrespondtoaUSPSeither5-or9-digitformat,carriersrejecttheclaimasunprocessableusingmessageN53ontheremittanceadviceinconjunctionwithreasoncode16.
IftheZIPcodeenteredontheclaimisnotintheCMS-suppliedZIPCodeFile,manuallyverifytheZIPcodetoidentifyapotentialcodingerrorontheclaimoranewZIPcodeestablishedbytheU.
S.
PostalService(USPS).
ZIPcodeinformationmaybefoundattheUSPSWebsiteathttp://www.
usps.
com/,orothercommerciallyavailablesourcesofZIPcodeinformationmaybeconsulted.
IfthisprocessvalidatestheZIPcode,theclaimmaybeprocessed.
AllsuchZIPcodesaretobeconsideredurbanZIPcodesuntilCMSdeterminesthatthecodeshouldbedesignatedasrural.
IfthisprocessdoesnotvalidatetheZIPcode,theclaimmustberejectedasunprocessableusingmessageN53ontheremittanceadviceinconjunctionwithreasoncode16.
30.
1.
4–CWFEditingofAmbulanceClaimsforInpatients(Rev.
668,Issued:09-02-05,Effective:01-03-06,Implementation:01-03-06)Hospitalbundlingrulesexcludepaymenttoindependentsuppliersofambulanceservicesforbeneficiariesinahospitalinpatientstay.
CWFperformsrejecteditstoincomingclaimsfromsuppliersofambulanceservices.
UponreceiptofahospitalinpatientclaimattheCWF,CWFsearchespaidclaimhistoryandcomparestheperiodbetweenthehospitalinpatientadmissionanddischargedatestothelineitemservicedateonanambulanceclaimbilledbyasupplier.
TheCWFwillgenerateanunsolicitedresponsewhenthelineitemservicedatefallswithintheadmissionanddischargedatesofthehospitalinpatientclaim.
Uponreceiptofanunsolicitedresponse,thecarrierwilladjusttheambulanceclaimandrecoupthepayment.
Ambulanceserviceswithadateofservicethatisthesameastheadmissionordischargedateonaninpatientclaimareseparatelypayableandnotsubjecttothebundlingrules.
30.
2-IntermediaryGuidelines(Rev.
668,Issued:09-02-05,Effective:01-03-06,Implementation:01-03-06)ForSNFPartA,thecostoftransportationtoreceivemostservicesincludedintheRUGrateisincludedinthecostfortheservice.
Thisincludestransportationinanambulance.
PaymentfortheSNFclaimisbasedontheRUGs,andrecalibrationforfutureyearstakesintoaccountthecostoftransportationtoreceivetheancillaryservices.
IftheservicesareexcludedfromtheSNFPPSrate,theambulanceservicemaybebilledseparatelyascantheexcludedservice.
RefertoSection10.
5ofChapter3oftheMedicareClaimsProcessingManualforadditionalinformationonhospitalinpatientbundlingofambulanceservices.
Ingeneral,theintermediaryprocessesclaimsforPartBambulanceservicesprovidedbyanambulancesupplierunderarrangementswithhospitalsorSNFs.
TheseprovidersbillintermediariesusingonlyMethod2.
Theprovidermustfurnishthefollowingdatainaccordancewithintermediaryinstructions.
Theintermediarywillmakearrangementsforthemethodandmediaforsubmittingthedata:Adetailedstatementoftheconditionnecessitatingtheambulanceservice;Astatementindicatingwhetherthepatientwasadmittedasaninpatient.
Ifyesthenameandaddressofthefacilitymustbeshown;Nameandaddressofcertifyingphysician;Nameandaddressofphysicianorderingserviceifotherthancertifyingphysician;Pointofpickup(identifyplaceandcompletedaddress);Destination(identifyplaceandcompleteaddress);Numberofloadedmiles(thenumberofmilestraveledwhenthebeneficiarywasintheambulance);Costpermile;Mileagecharge;Minimumorbasecharge;andChargeforspecialitemsorservices.
Explain.
A.
GeneralThereasonablecostpertripofambulanceservicesfurnishedbyaproviderofservicesmaynotexceedtheprioryear'sreasonablecostpertripupdatedbytheambulanceinflationfactor.
ThisdeterminationiseffectivewithservicesfurnishedduringFederalFiscalYear(FFY)1998(betweenOctober1,1997,andSeptember30,1998).
ProvidersaretobillforPartBambulanceservicesusingthebillingmethodofbaserateincludingsupplies,withmileagebilledseparatelyasdescribedbelow.
Thefollowinginstructionsprovidebillingproceduresimplementingtheaboveprovisions.
B-ApplicableBillTypesTheappropriatetypeofbill(13X,22X,23X,83X,and85X)mustbereported.
ForSNFs,ambulancecannotbereportedona21Xtypeofbill.
C.
ValueCodeReportingForclaimswithdatesofserviceonorafterJanuary1,2001,providersmustreportoneveryPartBambulanceclaimvaluecodeA0(zero)andtherelatedZIPcodeofthegeographiclocationfromwhichthebeneficiarywasplacedonboardtheambulanceinFLs39-41"ValueCodes.
"Thevaluecodeisdefinedas"ZIPCodeofthelocationfromwhichthebeneficiaryisinitiallyplacedonboardtheambulance.
"Providersreportthenumberindollarportionoftheformlocationrightjustifiedtothelefttothedollar/centsdelimiter.
ProvidersutilizingtheUB-92flatfileuseRecordType41fields16-39.
OntheX-12institutionalclaimstransactions,providersshowHI*BE:A0:::12345~,2300Loop,HIsegment.
MorethanoneambulancetripmaybereportedonthesameclaimiftheZIPcodeofallpointsofpickuparethesame.
However,sincebillingrequirementsdonotallowforvaluecodes(ZIPcodes)tobelineitemspecificandonlyoneZIPcodemaybereportedperclaim,providersmustprepareaseparateclaimforabeneficiaryforeachtripifthepointsofpickuparelocatedindifferentZIPcodes.
D.
RevenueCode/HCPCSCodeReportingProvidersmustreportrevenuecode054Xand,forservicesprovidedbeforeJanuary1,2001,oneofthefollowingCMSHCPCScodesinFL44"HCPCS/Rates"foreachambulancetripprovidedduringthebillingperiod:A0030(discontinued12/31/2000);A0040(discontinued12/31/2000);A0050(discontinued12/31/2000);A0320(discontinued12/31/2000);A0322(discontinued12/31/2000);A0324(discontinued12/31/2000);A0326(discontinued12/31/2000);A0328,(discontinued12/31/2000);orA0330(discontinued12/31/2000).
Inaddition,providersreportoneofA0380orA0390formileageHCPCScodes.
NootherHCPCScodesareacceptableforreportingambulanceservicesandmileage.
Providersreportoneofthefollowingrevenuecodes:0540;0542;0543;0545;0546;or0548.
Donotreportrevenuecodes0541,0544,or0547.
ForclaimswithdatesofserviceonorafterJanuary1,2001,providersmustreportrevenuecode540andoneofthefollowingHCPCScodesinFL44"HCPCS/Rates"foreachambulancetripprovidedduringthebillingperiod:A0426;A0427;A0428;A0429;A0430;A0431;A0432;A0433;orA0434.
ProvidersusinganALSvehicletofurnishaBLSlevelofservicereportHCPCScode,A0426(ALS1)orA0427(ALS1emergency),andarepaidaccordingly.
Inaddition,allprovidersreportoneofthefollowingmileageHCPCScodes:A0380;A0390;A0435;orA0436.
SincebillingrequirementsdonotallowformorethanoneHCPCScodetobereportedforperrevenuecodeline,providersmustreportrevenuecode0540(ambulance)ontwoseparateandconsecutivelinestoaccommodateboththePartBambulanceserviceandthemileageHCPCScodesforeachambulancetripprovidedduringthebillingperiod.
Eachloaded(e.
g.
,apatientisonboard)1-wayambulancetripmustbereportedwithauniquepairofrevenuecodelinesontheclaim.
UnloadedtripsandmileageareNOTreported.
However,inthecasewherethebeneficiarywaspronounceddeadaftertheambulanceiscalledbutbeforetheambulancearrivesatthescene:PaymentmaybemadeforaBLSserviceifagroundvehicleisdispatchedoratthefixedwingorrotarywingbaserate,asapplicable,ifanairambulanceisdispatched.
Neithermileagenoraruraladjustmentwouldbepaid.
Theblendedrateamountwillotherwiseapply.
ProvidersreporttheA0428(BLS)HCPCScode.
ProvidersreportmodifierQL(Patientpronounceddeadafterambulancecalled)inFormLocator(FL)44"HCPCS/Rates"insteadoftheoriginanddestinationmodifier.
InadditiontotheQLmodifier,providersreportmodifierQMorQN.
E.
ModifierReportingProvidersmustreportanoriginanddestinationmodifierforeachambulancetripprovidedinFL44"HCPCS/Rates.
"Originanddestinationmodifiersusedforambulanceservicesarecreatedbycombiningtwoalphacharacters.
Eachalphacharacter,withtheexceptionofx,representsanorigincodeoradestinationcode.
Thepairofalphacodescreatesonemodifier.
Thefirstpositionalphacodeequalsorigin;thesecondpositionalphacodeequalsdestination.
Originanddestinationcodesandtheirdescriptionsarelistedbelow:D-Diagnosticortherapeuticsiteotherthan"P"or"H"whentheseareusedasorigincodes;E-Residential,Domiciliary,CustodialFacility(otherthanan1819facility);H-Hospital;I-Siteoftransfer(e.
g.
airportorhelicopterpad)betweenmodesofambulancetransport;J-Nonhospitalbaseddialysisfacility;N-SkilledNursingFacility(SNF)(1819facility);P-Physician'soffice(IncludesHMOnonhospitalfacility,clinic,etc.
);R-Residence;S-Sceneofaccidentoracuteevent;orX-(DestinationCodeOnly)intermediatestopatphysician'sofficeenroutetothehospital.
(IncludesHMOnonhospitalfacility,clinic,etc.
)Inaddition,providersmustreportoneofthefollowingmodifierswitheveryHCPCScodetodescribewhethertheservicewasprovidedunderarrangementordirectly:QM-Ambulanceserviceprovidedunderarrangementbyaproviderofservices;orQN-Ambulanceservicefurnisheddirectlybyaproviderofservices.
F.
Line-ItemDatesofServiceReportingProvidersarerequiredtoreportline-itemdatesofserviceperrevenuecodeline.
Thismeansthattheymustreporttwoseparaterevenuecodelinesforeveryambulancetripprovidedduringthebillingperiodalongwiththedateofeachtrip.
Thisincludessituationsinwhichmorethanoneambulanceserviceisprovidedtothesamebeneficiaryonthesameday.
Line-itemdatesofservicearereportedonthehardcopyUB-92inFL45"ServiceDate"(MMDDYY),andonRT61,field13,"DateofService"(YYYYMMDD)ontheUB-92flatfile.
G.
ServiceUnitsReportingForlineitemsreflectingHCPCScodeA0030,A0040,A0050,A0320,A0322,A0324,A0326,A0328,orA0330(servicesbeforeJanuary1,2001)orcodeA0426,A0427,A0428,A0429,A0430,A0431,A0432,A0433,orA0434(servicesonandafterJanuary1,2001),providersarerequiredtoreportinFL46"ServiceUnits"eachambulancetripprovidedduringthebillingperiod.
Therefore,theserviceunitsforeachoccurrenceoftheseHCPCScodesarealwaysequaltoone.
Inaddition,forlineitemsreflectingHCPCScodeA0380orA0390,thenumberofloadedmilesmustbereported.
(Seeexamplesbelow.
)Therefore,theserviceunitsforeachoccurrenceoftheseHCPCScodesarealwaysequaltoone.
Inaddition,forlineitemsreflectingHCPCScodeA0380,A0390,A0435,orA0436,thenumberofloadedmilesmustbereported.
H.
TotalChargesReportingForlineitemsreflectingHCPCScode:A0030,A0040,A0050,A0320,A0322,A0324,A0326,A0328,orA0330(servicesbeforeJanuary1,2001);ORHCPCScodeA0426,A0427,A0428,A0429,A0430,A0431,A0432,A0433,orA0434(onorafterJanuary1,2001);ProvidersarerequiredtoreportinFL47"TotalCharges"theactualchargefortheambulanceserviceincludingallsuppliesusedfortheambulancetripbutexcludingthechargeformileage.
ForlineitemsreflectingHCPCScodeA0380,A0390,A0435,orA0436,reporttheactualchargeformileage.
NOTE:Thereareinstanceswheretheproviderdoesnotincuranycostformileage,e.
g.
,ifthebeneficiaryispronounceddeadaftertheambulanceiscalledbutbeforetheambulancearrivesatthescene.
Inthesesituations,providersreportthebaserateambulancetripandmileageasseparaterevenuecodelines.
Providersreportthebaserateambulancetripinaccordancewithcurrentbillingrequirements.
Forpurposesofreportingmileage,theymustreporttheappropriateHCPCScode,modifiers,andunitsasaseparatelineitem.
Fortherelatedcharges,providersreport$1.
00inFL48fornoncoveredcharges.
IntermediariesshouldassignANSIGroupCodeOAtothe$1.
00noncoveredmileageline,whichinturninformsthebeneficiariesandprovidersthattheyeachhavenoliability.
PriortosubmittingtheclaimtoCWF,theintermediarywillremovetheentirerevenuecodelinecontainingthemileageamountreportedinFL48"NoncoveredCharges"toavoidnonacceptanceoftheclaim.
EXAMPLES:ThefollowingprovidesexamplesofhowbillsforPartBambulanceservicesshouldbecompletedbasedonthereportingrequirementsabove.
Theseexamplesreflectambulanceservicesfurnisheddirectlybyproviders.
AmbulanceservicesprovidedunderarrangementbetweentheproviderandanambulancecompanyarereportedinthesamemannerexceptprovidersreportaQMmodifierinsteadofaQNmodifier.
ThefollowingexamplesareforclaimssubmittedwithdatesofserviceonorafterJanuary1,2001.
EXAMPLE1-Claimcontainingonlyoneambulancetrip:FortheUB-92FlatFile,providersreportasfollows:ModifierRecordTypeRevenueCodeHCPCSCode#1#2DateofServiceUnitsTotalCharges610540A0428RHQN0827011(trip)100.
00610540A0380RHQN0827014(mileage)8.
00ForthehardcopyUB-92(FormCMS-1450),providersreportasfollows:FL42FL44FL45FL46FL470540A0428RHQN0827011(trip)100.
000540A0380RHQN0827014(mileage)8.
00EXAMPLE2-Claimcontainingmultipleambulancetrips:FortheUB-92FlatFile,providersreportasfollows:ModifierRecordTypeRevenueCodeHCPCSCode#1#2DateofServiceUnitsTotalCharges610540A0429RHQN0828011(trip)100.
00610540A0380RHQN0828012(mileage)4.
00610540A0330RHQN0829011(trip)400.
00610540A0390RHQN0829013(mileage)6.
00610540A0426RHQN0830011(trip)500.
00610540A0390RHQN0830015(mileage)10.
00610540A0390RHQN0829013(mileage)6.
00610540A0426RHQN0830011(trip)500.
00ForthehardcopyUB-92(FormCMS-1450),providersreportasfollows:ModifierFL42FL44#1#2FL45FL46FL470540A0429RHQN0828011(trip)100.
000540A0380RHQN0828012(mileage)4.
00EXAMPLE3-Claimcontainingmorethanoneambulancetripprovidedonthesameday:FortheUB-92FlatFile,providersreportasfollows:ModifierRecordTypeRevenueCodeHCPCSCode#1#2DateofServiceUnitsTotalCharges610540A0429RHQN0902011(trip)100.
00610540A0380RHQN0902012(mileage)4.
00610540A0429HRQN0902011(trip)100.
00610540A0380HRQN0902012(mileage)4.
00ForthehardcopyUB-92(CMS-1450),providersreportasfollows:ModifierFL42FL44#1#2FL45FL46FL470540A0429RHQN0902011(trip)100.
000540A0380RHQN0902012(mileage)4.
000540A0429HRQN0902011(trip)100.
000540A0380HRQN0902012(mileage)4.
00I.
EditsIntermediariesedittoassureproperreportingasfollows:ForclaimswithdatesofservicebeforeJanuary1,2001,eachpairofrevenuecodes0540musthaveoneofthefollowingambulancetripHCPCScodes-A0030,A0040,A0050,A0320,A0322,A0324,A0326,A0328orA0330;andoneofthefollowingmileageHCPCScodes-A0380orA0390;ForclaimswithdatesofserviceonorafterJanuary1,2001,eachpairofrevenuecodes0540musthaveoneofthefollowingambulanceHCPCScodes-A0426,A0427,A0428,A0429,A0430,A0431,A0432,A0433,orA0434;andoneofthefollowingmileageHCPCScodes–A0435,A0436orforclaimswithdatesofservicebeforeApril1,2002,A0380,orA0390,orforclaimswithdatesofserviceonorafterApril1,2002,A0425;ForclaimswithdatesofserviceonorafterJanuary1,2001,thepresenceofanoriginanddestinationmodifierandaQMorQNmodifierforeverylineitemcontainingrevenuecode0540;Theunitsfieldiscompletedforeverylineitemcontainingrevenuecode0540;ForclaimswithdatesofserviceonorafterJanuary1,2001,theunitsfieldiscompletedforeverylineitemcontainingrevenuecode0540;ServiceunitsforlineitemscontainingHCPCScodesA0030,A0040,A0050,A0320,A0322,A0324,A0326,A0328,A0330,A0426,A0427,A0428,A0429,A0430,A0431,A0432,A0433,orA0434alwaysequal"1"ForclaimswithdatesofserviceonorafterJuly1,2001,each1-wayambulancetrip,line-itemdatesofservicefortheambulanceservice,andcorrespondingmileageareequal.
30.
2.
1-Provider/IntermediaryBillProcessingGuidelinesEffectiveApril1,2002,asaResultofFeeScheduleImplementation(Rev.
668,Issued:09-02-05,Effective:01-03-06,Implementation:01-03-06)PMsAB-00-88,AB-00-118,A3-3660.
1,PMA-01-48,SNF539,HHA477,HO433,CindyMurphyandBarbaraGriffene-mail,PMsAB-00-118,AB-00-131TheseinstructionsareforclaimswithdatesofserviceonorafterApril1,2002.
Instructionscontainedin§30.
2areapplicableforclaimswithdatesofservicepriortoApril1,2002.
ForSNFPartA,thecostoftransportationtoreceivemostservicesincludedintheRUGrateisincludedinthecostfortheservice.
Thisincludestransportationinanambulance.
PaymentfortheSNFclaimisbasedontheRUGs,andrecalibrationforfutureyearstakesintoaccountthecostoftransportationtoreceivetheancillaryservices.
IftheservicesareexcludedfromtheSNFPPSrate,theambulanceservicemaybebilledseparatelyascantheexcludedservice.
RefertoSection10.
5ofChapter3oftheMedicareClaimsProcessingManualforadditionalinformationonhospitalinpatientbundlingofambulanceservices.
Ingeneral,theintermediaryprocessesclaimsforPartBambulanceservicesprovidedbyamambulancesupplierunderarrangementswithhospitalsorSNFs.
TheseprovidersbillintermediariesusingonlyMethod2.
Theprovidermustfurnishthefollowingdatainaccordancewithintermediaryinstructions.
Theintermediarywillmakearrangementsforthemethodandmediaforsubmittingthedata:Adetailedstatementoftheconditionnecessitatingtheambulanceservice;Astatementindicatingwhetherthepatientwasadmittedasaninpatient.
Ifyesthenameandaddressofthefacilitymustbeshown;Nameandaddressofcertifyingphysician;Nameandaddressofphysicianorderingserviceifotherthancertifyingphysician;Pointofpickup(identifyplaceandcompletedaddress);Destination(identifyplaceandcompleteaddress);Numberofloadedmiles(thenumberofmilestraveledwhenthebeneficiarywasintheambulance);Costpermile;Mileagecharge;Minimumorbasecharge;andChargeforspecialitemsorservices.
Explain.
A-RevenueCodeReportingProvidersreportambulanceservicesunderrevenuecode540inFL42"RevenueCode.
"B-HCPCSCodesReportingProvidersreportthenewHCPCScodesestablishedfortheambulancefeeschedule.
NootherHCPCScodesareacceptableforthereportingofambulanceservicesandmileage.
ThenewHCPCScodemustbeusedtoreflectthetypeofservicethebeneficiaryreceived,notthetypeofvehicleused.
(NotallpreviousHCPCScodesareapplicabletoproviderssinceprovidershavebeenreportingtheall-inclusiverateandmileagecodesasdescribedin§30.
2.
)ProvidersmustreportoneofthefollowingHCPCScodesinFL44"HCPCS/Rates"foreachbaserateambulancetripprovidedduringthebillingperiod:A0426;A0427;A0428;A0429;A0430;A0431;A0432;A0433;orA0434.
ThesearethesamecodesrequiredeffectiveforservicesJanuary1,2001.
Inaddition,providersmustreportoneofHCPCSmileagecodes:A0425;A0435;orA0436.
SincebillingrequirementsdonotallowformorethanoneHCPCScodetobereportedperrevenuecodeline,providersmustreportrevenuecode540(ambulance)ontwoseparateandconsecutivelineitemstoaccommodateboththeambulanceserviceandthemileageHCPCScodesforeachambulancetripprovidedduringthebillingperiod.
Eachloaded(e.
g.
,apatientisonboard)1-wayambulancetripmustbereportedwithauniquepairofrevenuecodelinesontheclaim.
UnloadedtripsandmileageareNOTreported.
Providerscodeonemilefortripslessthanamile.
Milesmustbeenteredaswholenumbers.
Ifatriphasafractionofamile,rounduptothenearestwholenumber.
C-ModifierReportingProvidersmustreportanoriginanddestinationmodifierforeachambulancetripprovidedandeitheraQM(Ambulanceserviceprovidedunderarrangementbyaproviderofservices)orQN(Ambulanceservicefurnisheddirectlybyaproviderofservices)modifierinFL44"HCPCS/Rates".
D-ServiceUnitsReportingForlineitemsreflectingHCPCScodesA0426,A0427,A0428,A0429,A0430,A0431,A0432,A0433,orA0434,providersarerequiredtoreportinFL46"ServiceUnits"foreachambulancetripprovided.
Therefore,theserviceunitsforeachoccurrenceoftheseHCPCScodesarealwaysequaltoone.
Inaddition,forlineitemsreflectingHCPCScodeA0425,A0435,orA0436,providersmustalsoreportthenumberofloadedmiles.
E-TotalChargesReportingForlineitemsreflectingHCPCScodesA0426,A0427,A0428,A0429,A0430,A0431,A0432,A0433,orA0434,providersarerequiredtoreportinFL47,"TotalCharges,"theactualchargefortheambulanceserviceincludingallsuppliesusedfortheambulancetripbutexcludingthechargeformileage.
ForlineitemsreflectingHCPCScodesA0425,A0435,orA0436,providersaretoreporttheactualchargeformileage.
NOTE:Thereareinstanceswheretheproviderdoesnotincuranycostformileage,e.
g.
,ifthebeneficiaryispronounceddeadaftertheambulanceiscalledbutbeforetheambulancearrivesatthescene.
Inthesesituations,providersreportthebaserateambulancetripandmileageasseparaterevenuecodelines.
Providersreportthebaserateambulancetripinaccordancewithcurrentbillingrequirements.
Forpurposesofreportingmileage,theymustreporttheappropriateHCPCScode,modifiers,andunits.
Fortherelatedcharges,providersreport$1.
00innoncoveredcharges.
IntermediariesshouldassignANSIGroupCodeOAtothe$1.
00noncoveredmileageline,whichinturninformsthebeneficiariesandprovidersthattheyeachhavenoliability.
NOTE:ForMethod3and4billers,alsoreportthesupplies,etc.
,separatelythroughthetransitionperiod.
Theappropriatesubmittedamountforsupplies,etc.
,shouldbeenteredforeachservice.
F-Edits(IntermediaryClaimsWithDatesofServiceOnorAfter4/1/02)ForclaimswithdatesofserviceonorafterApril1,2002,intermediariesperformthefollowingeditstoassureproperreporting:Edittoassureeachpairofrevenuecodes540haveoneofthefollowingambulanceHCPCScodes-A0426,A0427,A0428,A0429,A0430,A0431,A0432,A0433,orA0434;andoneofthefollowingmileageHCPCScodes-A0425,A0435,orA0436.
Edittoassurethepresenceofanorigin,destinationmodifier,andaQMorQNmodifierforeverylineitemcontainingrevenuecode540;Edittoassurethattheunit'sfieldiscompletedforeverylineitemcontainingrevenuecode540;EdittoassurethatserviceunitsforlineitemscontainingHCPCScodesA0426,A0427,A0428,A0429,A0430,A0431,A0432,A0433,orA0434alwaysequal"1";andEdittoassureoneveryclaimthatrevenuecode540,avaluecodeofA0(zero),andacorrespondingZIPcodearereported.
IftheZIPcodeisnotavalidZIPcodeinaccordancewiththeUSPSassignedZIPcodes,intermediariesverifytheZIPcodetodetermineiftheZIPcodeisacodingerrorontheclaimoranewZIPcodefromtheUSPSnotontheCMSsuppliedZIPCodeFile.
G-CWF(Intermediaries)Intermediariesreporttheprocedurecodesinthefinancialdatasection(field65a-65j).
Theyincluderevenuecode,HCPCScode,units,andcoveredchargesintherecord.
WheremorethanoneHCPCScodeprocedureisapplicabletoasinglerevenuecode,theproviderreportseachHCPCScodeandrelatedchargeonaseparateline,andtheintermediaryreportsthistoCWF.
Reportthepaymentamountbeforeadjustmentforbeneficiaryliabilityinfield65g"Rate"andtheactualchargeinfield65h,"CoveredCharges.
"H-ProviderStatisticsandReimbursementReport(PS&R)(Intermediaries)Toassurethattheprovidersreceivethecorrectpaymentamountduringthetransitionperiod,allsubmittedchargesattributabletoambulanceservicesfurnishedduringacost-reportingperiodareaggregatedandtreatedseparatelyfromthesubmittedchargesattributabletoallotherservicesfurnishedintheprovider.
Inaddition,thenecessarystatisticsaremaintainedfortheProviderStatistics&ReimbursementReport(PS&R).
Thisensuresthattheambulancefeescheduleportionoftheblendedtransitionpaymentisnotcostsettledatcostsettlementtime.
SeethePS&Rguidelinesforspecificinformation.